Self-managed abortion: Barriers and opportunities in humanitarian settingsin East Africa

Abstract

This study articulates the need for refugees to have better access to abortion information and services, provides recommendations for how they can safely manage their abortions, and creates an impetus for stakeholders to address this issue. Ultimately, our findings can inform future efforts to reduce unsafe abortions, and maternal morbidity and mortality. However, many refugees who might benefit from this research do not have access to libraries, scientific journals, or even the internet, so engaging them and creating a learning experience is essential to sharing this knowledge.

Introduction

Our consortium consists of members from research, humanitarian, and academic settings across the US and the East Africa region. Abortion research has brought these partners together in various configurations in the past. Ibis Reproductive Health and Ipas have collaborated to measure quality of care in abortion and to conduct rigorous research on abortion in South Africa. Ibis, Ipas, and the African Population and Health Research Centre have worked together to study abortion and infanticide in Senegal, and to understand and measure abortion complications. Ipas and the International Rescue Committee (IRC) have engaged in efforts to improve global access to safe abortion in humanitarian settings for over a decade. Resilience Action International (RAI) is a non-profit, refugee-led organization based in Kakuma Refugee Camp, Kenya, that works to broaden understanding of refugee’s lives and livelihoods in East Africa. We hope to leverage the momentum of existing and past successes, build new and stronger partnerships, and expand reproductive rights and autonomy through this research.

Who should benefit?

Approximately 60% of maternal deaths take place in countries and settings affected by conflict, displacement, and natural disasters. Many are preventable with access to safe and legal abortion care or evidence-based information on self-managed abortion (SMA). Displaced and conflict-affected females are at increased risk of the consequences of lack of access to abortion care, including forced childbearing, and morbidity and mortality. Despite many calls for additional research, funding, and attention towards provision of safe abortion services for women in these settings, little is known about their experiences or the barriers and facilitators to expanding abortion access in humanitarian contexts.

A growing body of evidence demonstrates that women can safely and effectively terminate their own pregnancies using mifepristone and misoprostol, or misoprostol alone. Interventions that seek to expand access to information on SMA have the potential to revolutionize access to safe abortion. The benefits of these scientific advances have been largely ignored in humanitarian contexts due to a lack of political will.

The partners collaborating in this multi-sectoral academic, health, and humanitarian project each brought different strengths to the research. Our objectives were to document the abortion experiences of displaced women and girls with a focus on SMA and information access in Kakuma Refugee Camp and Bidibidi Refugee Settlement, Uganda. We examined differences in abortion experience based on displacement, humanitarian setting, and legal context, and estimated the abortion incidence, rate, and ratio using respondent-driven sampling (RDS) and an innovative adaptation of the Abortion Incidence Complications Methodology (AICM).

Establishing and building a multi-sectoral partnership during COVID-19, with its global and organizational travel restrictions, involved fostering trust and getting to know one another through dozens of online virtual meetings. Guided by our RAI partners, we spent time together thinking about our roles and how we might make our research on a topic that is often not spoken about in this community both engaging and impactful.

Engagement

Our work sought to address the increased need for abortion in humanitarian settings due to the collapse of healthcare systems, resource constraints common in chronic emergency settings, gaps in contraceptive access and use, and increased exposure to sexual violence or transactional sex. In part due to the difficulty of collecting data in humanitarian settings, there is little research on the abortion experiences of those living under these circumstances, or the barriers and facilitators to expanding abortion access in such situations. Understanding these issues can aid the development of programs and policies to increase access to safe abortion.

Examining abortion experiences requires a holistic view that explores the micro-, macro-, individual-, and institutional-level barriers. Those faced by females living in the Kakuma Refugee Camp are plentiful. Located in a remote area of Northwestern Kenya, it was initially home to 8,000 people in one of the poorest regions of the country. Since 1992, it has grown to accommodate people displaced from war-torn Sudan, Somalia, and Ethiopia, and is now home to almost 200,000 refugees.

Only 2% of the refugees in this camp complete their secondary school education, and girls represent only 20% of students overall. Refugees in the camp are dependent on food rations and a small amount of cash assistance provided to registered households.

Travel outside of the camp is allowed only with permission and a 5 PM curfew is applied. Employment is restricted except for the small number of refugees who work as incentive staff for non-governmental organizations (NGOs) for US$20‒40 a month, far less than what a Kenyan would be paid for the same position.

This reality was far removed from that of our academic partners, and we were continually challenged to engage and understand more by our RAI partners on the ground in Kenya.

Research

The work was intentionally inclusive by partnering with a refugee-led agency based in Kakuma Camp; pairing more-experienced data collectors from urban areas with refugee data collectors to build their skills; involving women living in the refugee camps as respondents (known as ‘seeds’) for the RDS process, as research informants, and as community advisory board (CAB) members; and applying user-centred design strategies to determine the most resonant messaging for the community based on research findings.

These concepts of community participation were well-suited to our study design. A key component of a successful RDS study is involving engaged and enthusiastic community member with their own abortion experiences (seeds) in the research process, to generate community buy-in and gather important input about the appropriateness of proposed sampling methodologies, recruitment strategies, and so on. Recruiting community advisors from among interested members and building a supportive network of peers ensures input from the direct constituents and beneficiaries of the work.

We identified and recruited seeds from among those who had direct abortion experiences and a personal understanding of the research topic. We invested in their professional skills and knowledge to ensure that they could fully participate in meetings and decisions. Every member of our study team participated in abortion values clarification and examination activities, research and interviewing skills and activities, and exercises to improve their knowledge of sexual and reproductive rights, especially abortion.

Our data collectors and community advisors were engaged throughout the course of study planning, field testing, data collection, and result sharing. They provided input on capacity building, ethics, question domains, recruitment strategies (particularly around protection of confidentiality), remuneration, unanticipated challenges, dissemination and research uptake, and intervention development.

Engagement with the wider study team occurred at several points including during the instrument-development phase before launch, and during the first quarter of data collection to troubleshoot implementation problems. They also convened to review preliminary results, and to discuss dissemination strategies.

Translating into impact

Understanding women’s abortion experiences in humanitarian settings—including unsafe abortion, pathways to SMA, access to medications, support systems, care-seeking decisions, and stigma—is key to the development of interventions that adequately meet their needs. Incorporating the input of those directly affected by the issue under study was essential. By engaging with refugee experts and sharing our research skills, we hoped to magnify our findings for beneficiaries who are often overlooked. This knowledge is too useful and important to be simply left with policymakers and academics.

A supplemental funding opportunity offered by our donor to improve research impact allowed us to look for additional ways to engage more fully with our refugee and community stakeholders. Reaching research beneficiaries is always challenging. We used the funds to organize a user-centred design workshop within the camp, both to share findings and to co-create products with our beneficiaries that could be useful in the community. The week-long workshop was designed to develop multi-language, low-literacy messaging and products using research findings to improve information on unsafe abortion consequences, SMA, and hotline access; to provide safer evidence-based information and referrals; and to help RAI update its sexual and reproductive health and rights programming curriculum and volunteer network with improved abortion content for community engagement activities. The coordination, facilitation, and implementation of this workshop could not have occurred without the dedication of our study team staff, data collectors, and CAB members.